Ethical Dilemma with Treating Unethical Patients

March 3, 2008 at 11:51 pm 10 comments

I have been struggling with an ethical dilemma ever since my Level I fieldwork assignment, where I was doing my clinical at an outpatient facility within a hospital located near one of the local jails.

Since this hospital was affiliated with the city, we often got the prisoners that needed occupational therapy at this facility.  If a prisoner is scheduled to come in for an appointment, they are accompanied by two police officers and their hands and feet are both shackled.

As part of our assessments, we typically ask our patients what their own goals are for therapy.   Unfortunately, I had one patient (who had had an ulnar nerve and tendon injury from a knife fight) tell me that his goal for therapy was “to be able to close my hand into a fist so that I can fight again.”

When I hear something like that, I think to myself, “Why do I want to treat this person?  Why do I want to help this person meet his goals?”

This question bothered my enough that I knew right away that I would never want to work with forensic patients.  As an occupational therapist, I know that we have to work with patients to meet their goals and increase their occupational well-being.  But if that involves beating up other people and doing illegal things, how can I, in good faith, treat this type of patient?


Entry filed under: Ethics, fieldwork, interviewing, occupational therapy, Open Questions, OT, phys dys, treatment. Tags: , , , , , .

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10 Comments Add your own

  • 1. Melissa  |  March 14, 2008 at 8:44 pm

    Try being a special ed. teacher and having your students tell you that they are only in school so they can receive their SSI Checks. It doesn’t matter why they are there…you have to do your best to provide the best possible education (or therapy) to them. Believe me, I know this can be hard sometimes.

  • 2. Mary  |  March 30, 2008 at 9:18 pm

    Hi! I read your post and I just wanted to say I know how you feel. I did a level two fieldwork in a behavioral health setting and I received many comments like that. The only advice I can give you is that a) sometimes people say things just to get a jump out of you or to make you mad. that patient obviously achieved that. and b) I know when one of my patients would say something like that to me I would tell them that it was inappropriate or say that we are going to remain positive or that goals need to be appropriate and positive, then they kind of know their limits are in therapy. Its ok to be uncomfortable in situations like that and maybe if it makes you that uncomfortable it is a area you shouldn’t be in.

  • 3. D  |  April 17, 2008 at 12:51 pm

    I was so disheartened to see this entry. I too am in OT student. I have been taught so many things in school but it will never amount to what i have learned growing up in a tough inner city where violence and drugs have killed too many friends and loved ones. A few friends are incareated paying for mistakes they made. I promise (unless the patient had antisocial PD) you the inmate you treated who wanted to be able to fight again was trying to tell you more. Maybe there is no ethical dilemma there at all. I agree with Mary sometimes people just try to get a rise out of you. It is much easier to show anger than fear. A man i once worked on with bilateral amputations from the elbow down told me that. He said it took 30 years for him to accept his disability and at times he was nasty. And in jail culture it is different from the safe places you eat, sleep and work in. For this man or woman not having use of his hand is a weakness and makes him prey. Makes him prey for beatings, abuse and rape so other prisoners can exude their strength and power as to not be the prey themselves. This man may deal with demons some of us could never imagine. While i agree you’d never get a job or a license to practice OT if you included fighting as an IADL and put it into your goals, i do not agree that this person does not deserve the right to regain use of his hand and the best treatment you can provide. We all decided to help someone and you could be the change in this person’s life. the person who listened and offered help instead of judgement. trust me he judges himself enough. i have worked with young adults in and out of the correctional department and never once in an inital meeting have they trusted me enough on the first day to tell me how sorry they were about mistakes made. so listen longer and with empathy because the world they are from may be so far from your own.

  • 4. anna  |  April 18, 2008 at 7:44 am

    I do understand your problem well. I worked with alcoholics, who were in prison, too. What I would like to say is: If you help a patient to make a fist again, you help him to use the fist to eat or to wash his clothes as well. Even if he wants to fight with his fist, you can focus on living activities.

  • 5. Linda Glass  |  December 2, 2008 at 8:33 pm


    These people are very ill, they need your help. If you help them they have a chance, but if no one does they will never improve. This is mental illness, they need help, not to be judged or blamed, as it is never their fault. This patient really needs your help so that he can live normally.

  • 6. Ciaran O'Hagan  |  January 14, 2009 at 5:06 pm

    I suppose you have to treat the service-user as any other patient. He may have just said this to get a reaction and even if it were true how could you justify not helping me when he uses his hands for a vast amount of daily occupations – if you didnt treat his hand he would lose function. One positive, he would not be able to fight, but then he would have difficult dressing, cooking, writing etc….

    Great dilemma though, really got me thinking…

    Similar to me when I did an Elderly Community Mental Health placement and went with another OT to meet a service -user who was previously convicted and jailed for being a paedophile – i was adamant that I would not shake his hand as i wasnt obliged to do so professionally and felt I could still maintain a professional relationship without ever getting too friendly – weird position to be in but thought provoking none the less

  • 7. Kristen  |  August 31, 2009 at 7:27 am

    This I find hilarious, if it where me I would give them some RO…We can all relate to this clients goal. Maybe, not in fighting terms, but think back when you were a teenager and your cerebellum wasn’t developed fully. I’m sure most people can tell some odd goals they had at that time! Hang in there, you may be the most positive role model this client needs!

  • 8. Kristen  |  August 31, 2009 at 7:29 am

    You may be a great role model. Alot, of times there lifestyle was/is pretty dysfunctional, so fighting may be the norm.

  • 9. megan kelly  |  April 9, 2010 at 3:16 pm

    A fist can also defend yourself againest other aggressors. As a COTA for 17 yrs I have met my share of these patients. 1 I taught to box again to reco0ver froma stroke. he got tired swung and almost hit me with the Correction officer watching. He stammered I am sorry and my 92 year old dementia pt female, stated Ah you hit like a girl. the patient stopped looked at her then me and said ahhhhhh man and giggled. needless to say everytime after that he laughed at me and said aw man. Show the man kindness and teach him what he asked just maybe you can also show him how a fist can stop a fight.

  • 10. Therapist Finder  |  August 30, 2010 at 6:59 am

    Your actions are harmful to yourself or to others: for instance, you are drinking too much alcohol, abusing drugs, or becoming overly argumentative and aggressive.


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